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RD542  Ed22  A  review  of  the  hist 


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A  Review  of  the  History  and 
Literature  of  Appendicitis 


BY 


GEORGE   M.    EDEBOHLS,   A.M.,  M.D. 


NtW    YimK 


Reprint  from  the  Medical  Record,  November  2^,  jSgg 


NEW  YORK  : 

THE   PUBLISHERS'   PRINTING  COMPANY 

32,  34  Lafayette  Place 

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A  Review  of  the  History  and 
Literature  of  Appendicitis 


BY 

GEORGE   M.    EDEBOHLS,  A.M.,  M.D. 


NEW   \OKfi 


Reprint  from  the  Medical  Record,  November  2j,  '^99 


NEW  YORK : 

THE    PUBLISHERS'    PRINTING  COMPANY 

32,  34  Lafayktte  Place 

iSgg 


A  REVIEW  OF  THE  HISTORY  AND  LITERA- 
TURE OF  APPENDICITIS. 

By    GEORGE   M.    EDEBOHLS,    A.M.,    M.D., 

NEW    YORK. 

During  the  early  part  of  the  present  year  the  writer 
had  occasion  to  look  up  one  or  two  points  in  connec- 
tion with  the  subject  of  appendicitis.  He  became  in- 
terested and  more  and  more  deeply  involved  in  the 
literature,  until  after  a  number  of  months,  during 
which  all  his  spare  moments  were  devoted  to  the  task, 
he  found  that  he  had  read  and  passed  in  review  about 
all  that  has  ever  been  written  upon  appendicitis.  The 
magnitude  of  the  labor  becomes  apparent  when  it  is 
stated"  that  the  literature  of  appendicitis,  up  to  and  in- 
clusive of  the  year  i8g8,  embraces  more  than  twenty- 
five  hundred  journal  articles,  dissertations,  and  books, 
all  but  a  very  small  fractional  part  of  which  the  writer 
has  consulted  in  the  original.  As  illustrating  the 
rapid  growth  of  the  literature  it  may  be  stated  that 
more  than  one-half  of  the  twenty-five  hundred  journal 
articles,  dissertations,  and  books  have  appeared  within 
the  past  five  years. 

Upon  the  conclusion  of  the  task,  and  at  the  sugges- 
tion of  the  editor  of  the  Medical  Record,  who  thought 
that  a  historical  review  of  the  subject  of  appendicitis 
might  interest  some  of  the  readers  of  his  journal,  the 
following  notes  were  arranged  for  publication. 

Nomenclature. — Epityphlitis,  ecphyaditis,  and  sco- 
lecoiditis  have  been  proposed  by  Kuester,  Morris,  and 
Gerster,  respectively,  as  synonyms  for  appendicitis. 
The  term  appendicitis,  however,  though  a  barbarism, 
is  too  firmly  established  by  long  and  universal  usage, 


both  among  the  profession  and  the  laity,  to  be  displaced 
at  this  late  day.  We  bow  to  the  inevitable,  and,  for 
reasons  which  have  been  well  set  forth  by  Ellis,""*  ac- 
cept the  term  appendicitis. 

General  Historical  Data. — The  early  history  of  ap- 
pendicitis is  merged  with  and  emerges  from  that  of 
iliac  phlegmon,  typhlitis,  paratyphlitis,  and  perityph- 
litis. Saracenus,  in  a  letter  dated  August  28,  1642, 
published  by  Roussel,^"*  describes  an  abscess  in  the 
right  iliac  region  with  discharge  of  fecal  matter  and 
fourteen  lumbricoid  worms,  possibly  the  most  ancient 
clear  case  of  perityphlitic  or  appendicular  abscess  on 
record.  A  number  of  similar  cases  were  published 
during  more  than  a  hundred  years  following,  before 
Mestivier,"^  in  1759,  recognized  appendicitis  as  a  dis- 
tinct entity.  Mestivier  incised  an  abscess  in  the  right 
groin,  in  a  woman  far  advanced  in  pregnancy,  and  on 
autopsy  found  at  the  bottom  of  the  abscess  the  appen- 
dix vermiformis  perforated  by  a  pin.  Toward  the  end 
of  the  eighteenth  and  during  the  early  half  of  the  nine- 
teeth  century,  appendicitis  with  perforation  and  abscess 
formation  was  often  found  in  the  dead-house  and  de- 
scribed  by  numerous  writers.  Yet,  as  late  as  1838,  so 
learned  a  man  as  Albers,'  writing  at  length  on  typhlitis 
and  perityphlitis,  does  not  even  mention  the  appendix — • 
proof  that  a  knowledge  of  the  existence  of  appendi- 
citis was  by  no  means  general  at  that  time.  The  com- 
pl  ications  and  sequelas  of  appendicitis,  especially  those 
fatal  in  character,  were  also  noted  during  the  early 
half  of  the  present  century.  In  1846  Landsberg""  re- 
ported two  cases  of  hernia,  one  inguinal  and  one  fem- 
oral, containing  the  appendix.  Hall,'"  Zdekauer,"'* 
Monks,^''  Ohlmacher,"^-"*  PoUosson,-''  Rotter,'"^'  Rou- 
tier,'""  Kayser,'''  Ginnard,'"  and  Gross'-"  iiave  since 
reported  like  experiences.  In  1847  ^^^'^  diagnosis  of 
appendicitis  began  to  be  made  during  life  by  Cless,'" 
Hancock,""  and  others.  In  the  fifties  Cless,''"  Bam- 
berger," and  Leudet'""'  reported  large  numbers  cf  per- 


sonal  observations  of  perforative  appendicitis  \vith 
autopsies;  Leudet,  for  example,  reporting  tliirteen 
cases  of  perforation  and  seventeen  cases  of  simple 
ulceration  of  the  appendix  observed  by  him  in  three 
years.  Skoda, ""^  in  1862,  noted  the  spontaneous  cure 
of  appendicitis  by  obliteration,  and  advises  a  "  harden- 
ing process  "  treatment  with  that  end  in  view.  V\ith,'" 
in  1879,  fully  described  peritonitis  appendicularis,  and 
Bierhoff,^^  in  1880,  gave  an  excellent,  full,  and  elabo- 
rate description  of  the  pathology  of  appendicitis,  mod- 
ern in  every  respect  except  as  to  bacteriology.  The 
classic  of  Fitz,'"^  which  appeared  in  1886,  may  fairly 
be  said  to  have  given  the  impetus  to  the  intense  and 
practical  study  of  appendicitis  of  latter  years. 

The  bacteriology  of  appendicitis  first  received  atten- 
tion in  189 1,  chiefly  at  the  hands  of  the  Frenchmen 
Adenot  ^  and  Gouillioud,'^®  soon  followed  by  Ecke- 
horn,'"^  Weir,='^°  Robb,"'  Hodenpyl,'^'  and  others. 

The  diagnosis  of  acute  appendicitis  was  advanced 
more*  than  by  all  previous  knowledge  combined,  by 
McBurney,^'^  when,  in  1889,  he  discovered  and  estab- 
lished the  value  of  *'  McBurney's  point."  The  intro- 
duction and  elaboration,  in  1894,  by  Edebohls,^"  of 
palpation  of  the  vermiform  appendix  finally  placed  us 
in  a  position  to  diagnose  clearly  and  positively  every 
case  of  chronic,  and  nearly  every  case  of  acute,  appen- 
dicitis. 

The  history  of  the  origin  and  development  of  the 
operative  treatment  of  perityphlitic  abscess  and  of  ap- 
pendicitis will  receive  full  attention  later  on  under  a 
special  heading. 

Frequency  of  Appendicitis As  regards  both  the 

frequency  of  appendicitis  and  its  relative  frequency  in 
the  two  sexes,  the  most  remarkable  and  apparently 
irreconcilable  statements  are  made  by  various  investi- 
gators. While  the  belief  is  current  that  appendici- 
tis affects  males  in  larger  proportion  than  females, 
Einhorn,'"  in  eighteen  thousand  successive  autopsies, 


found  perforating  appendicitis  in  0.55  per  cent,  of 
males  and  0.57  per  cent,  of  females,  and  Robinson^'* 
in  one  hundred  and  twenty-eight  autopsies  as  they 
came  found  evidences  of  past  peritonitis  on  and  about 
the  appendix  in  sixty-six  per  cent,  of  female  and  fifty- 
six  per  cent,  of  male  bodies. 

With ""  quotes  Toft  as  finding  in  three  hundred 
autopsies  one  hundred  and  ninety  entirely  normal 
appendices  and  one  hundred  and  ten  appendices  pre- 
senting more  or  less  evidences  of  disease.  Wallis/'^ 
on  the  contrary,  in  autopsies  extending  over  nearly  five 
years  found  only  1.7  per  cent,  of  all  appendices  pre- 
senting evidences  of  disease.  Fitz,"*"'  in  1886,  reports 
two  hundred  and  fifty-seven  cases  of  perforative  appen- 
dicitis observed  by  him  post  mortem,  and  comments 
upon  the  frequency  with  which  autopsy  shows  long- 
standing chronic  inflammation  without  acute  attacks. 
Ribbert '"  and  Zuckerkandl  ^'^  have  given  us  post-mor- 
tem statistics  of  obliterating  appendicitis.  The  for- 
mer, in  four  hundred  autopsies,  found  the  appendix 
partially  obliterated  in  21.5  per  cent,  and  completely 
obliterated  in  3.5  percent.;  the  latter,  in  two  hundred 
and  thirty-two  examinations,  found  9.9  per  cent,  of 
partial  and  13.8  per  cent,  of  complete  inflammatory 
obliteration  of  the  lumen  of  the  appendix.  Clinically^ 
Edebohls'"'  finds  that  four  per  cent,  of  all  women  have 
appendicitis. 

Anatomy  of  the  Vermiform  Appendix. — Accord- 
ing to  Kelynack,'"  the  existence  of  the  appendix  does 
not  appear  to  have  been  recognized  previous  to  the 
sixteenth  century,  when  it  was  described  by  Carpi, 
Estienne,  and  Vidus  Vidius,  the  latter  of  whom  applied 
the  qualifying  term  "vermiform."  Santorini  and  Sa- 
batier  described  it  quite  satisfactorily  in  the  seven- 
teenth century.  But  it  is  only  since  the  appearance  of 
the  classic  of  Lieberkiihn,^"^  in  1739,  and  that  of 
Vosse,^"  in  1749,  that  a  description  of  the  vermiform 
appendix  has  found  its  way  into  every  text-book  of 
anatomy. 


Finnell,"^  in  1S69,  measured  fifty  male  and  fifty 
female  appendices,  and  found  the  appendix  averaged 
one-half  inch  longer  in  women  than  in  men.  Mott,"" 
Biggs, '^  Dade,'"*  and  others  have  put  on  record  excep- 
tionally long  appendices.  The  general  anatomy  of 
the  appendix  has  received  consideration  at  the  hands 
of  Hewson,'"'  Ribbert,"'  and  many  others.  Ribbert's 
macro-  and  microscopical  examinations  of  four  hun- 
dred appendices  deserve  special  mention.  The  varia- 
tions of  position  observed  post  mortem  have  been 
minutely  investigated  by  Bryant.^"  The  peritoneal 
folds  and  fossae  in  the  immediate  neighborhood  of  the 
appendix  are  fully  described  and  pictured  by  Lock- 
wood  and  Rolleston,'""^  Kelynack,'"'  and  Jonnesco.'^' 
Swan^""  records  the  only  well-authenticated  case  of 
congenital  absence  of  the  appendix. 

Etiology  of  Appendicitis. — The  causative  factors 
in  the  production  of  appendicitis  are  universally  ad- 
mitted by  all  writers  to  be  very  generally  local  in 
character.  Fox,'"^  in  1885,  called  attention  to  the 
analogy  between  quinsy  and  appendicitis,  in  both  of 
which  lymphoid  tissues  identical  in  structure  were  in- 
volved. Atkinson'^  and  Bloomfield,^'"  in  1895,  dis- 
cussed heredity  as  a  cause,  and  "family  appendicitis" 
was  again  brought  forward  by  Faisans"'  in  1896.  In 
1891  Adenot^  and  Gouillioud  '^'''  developed  the  impor- 
tant role  played  by  bacteria  in  the  etiology  of  appen- 
dicitis. In  1895  and  1896  quite  a  crop  of  general 
causes  of  appendicitis  sprang  up  in  the  literature. 
Frazer'-"  writes  of  uratic  typhlitis,  Matthieu""'  of  la 
lithiase  appe?idiculaire,  and  Simons'"  describes  a  case 
of  gouty  appendicTtis.  Rheumatism  was  advanced  as 
a  cause  by  Sutherland,"'  followed  by  Beverley  Robin- 
son.■"■'  Byron  Robinson"***  finds  the  chief  exciting 
cause  of  appendicitis  in  the  action  of  the  psoas  mus- 
cle. La  grippe  is  considered  by  a  number  of  New 
York  physicians  of  prominence  and  large  experience  a 
frequent  cause  of  attacks  of  appendicitis.     The  etiol- 


8 


Ogy  of  relapses  has  been  carefully  and  minutely 
studied  by  von  Miyer.^^^  Goluboff  "'^  calls  appendi- 
citis an  epidemic  infectious  disease.  Edebohls'""  has 
pointed  out  the  role  played  by  movable  right  kidney 
in  the  production  of  appendicitis. 

Pathology  of  Appendicitis. — The  general  gross 
pathglogy  of  appendicitis  has  received  full  attention  in 
the  writings  of  Leudet,'"'  With,"'  Bierhof,=''  Porter,''^' 
Fitz,''®  and  numerous  others.  Thd  microscopical  ap- 
pearances have  been  carefully  studied  by  Craig," 
Ribbert,'"""  Letulle  and  Weinberg.^""  The  spontaneous 
cure  of  appendicitis  by  obliteration  was  noted  by 
Skoda*"*  in  1862.  and  the  cure  of  perforation  of  the 
appendix  by  the  same  process  was  recorded  by  Pep- 
per^*'^  in  1857.  Later,  Senn,""  Zuckerkandl,  '"  and 
Piersol"'"  wrote  on  "  appendicitis  obliterans,"  the  last- 
named  author  designating  it  nature's  cure.  Catarrhal 
appendicitis,  though  generally  recognized,  has  received 
but  scant  description,  the  only  noteworthy  contribu- 
tion, perhaps,  being  that  of  Deaver.'"  The  pathology 
of  interval  cases  is  well  described  and  pictured  by 
Abbe.'  "Appendicite  sous-he'patique  "  is  considered 
worthy  of  special  description  by  Glantenay."*^  The 
homology  of  appendicitis  with  salpingitis  is  insisted 
upon  by  Delbet."*  A  solitary  case  of  intramural  ab- 
scess of  the  appendix  is  recorded  by  Pilliet,"'"  and  a 
solitary  observation  cf  suppurative  typhlitis  with  a 
normal  appendix  by  Lop.'*'* 

Foreign  Bodies  in  the  Appendix. — In  former  years 
foreign  bodies  in  the  appendix  were  considered  under 
the  head  of  etiology  of  appendicitis.  In  the  light  of 
modern  views  the  permanent  lodgment  of  foreign 
bodies  in  the  appendix  is  probably  more  frequently 
the  result  than  the  cause  cf  appendicitis.  In  the  fol- 
lowing list,  by  no  means  complete,  of  foreign  bodies 
found  in  the  appendix,  reference  to  publication  is 
omitted. 

Entozoa  have  been  found   in  the  appendix  in  the 


following  varieties :  Ascarides  lumbricoides  (Becque- 
rel,  Patterson,  Lang,  Buck,  Cuthbertson) ;  Oxyuris 
vermicularis  (Bierhof ) ;  Tricocephalus  dispar  (Bier- 
hof). 

Coproliths  have  been  found  by  everybody  who  has 
had  much  to  do  with  post-mortem  investigations  or 
with  the  surgery  of  the  appendix.  Next  to  coproliths, 
pins  have  been  the  foreign  bodies  most  frequently  met 
in  the  appendix  (Mestivier,  Hewitt,  Joffroy,  Legg, 
Boussi,  Ashby,  Shoemaker,  McPhaedran,  Calmer,  Van- 
derveer,  Park). 

Other  foreign  bodies  found  in  the  appendix  are: 
grape  seeds  (Briske,  Pepper,  Noyes,  Kebb)  ;  melon 
seeds  (Tavignot,  Malespine,  Edebohls) ;  a  chocolate 
nut  (Prescott);  a  grain  of  oat  (Price,  Howe);  cherry 
stones  (Theurer,  Werner,  Reignier,  Ferguson,  For- 
mad) ;  raspberry  seeds  (Vedder,  Craig) ;  prune  stones 
(Vidal,  Stuetzle) ;  a  date  seed  (Leaman) ;  orange  seeds 
(Thornton,  Service) ;  a  bean  (Cliquet,  Haeker,  Wy- 
man)  ;  tomato  seeds  (Edebohls);  a  fruit  stone  (Fir- 
ket) ;  huckleberry  seeds  (Brundage) ;  blackberry  seeds 
(Vanderveer,  Wilson)  ;  shell  of  hazelnut  (Southam) ; 
a  piece  of  chestnut  (Owens,  Formad) ;  peanuts  (Rosen- 
heimer) ;  hair  (Peterson,  Hildebrandt) ;  a  bristle 
(Ward,  Gibbons,  Ulloa  y  Geralt);  a  glazier's  point  of 
zinc  (Bartlett) ;  a  globule  of  solder  (Morton) ;  a  gela- 
tin capsule  (Roberts) ;  a  piece  of  bone  (Ferguson, 
Coleman);  apiece  of  screw  nail  (Ferguson);  a  rifle 
cartridge  (Ransohoff);  fin  of  a  fish  (Ashton);  knot  of 
a  heavy  silk  ligature  from  a  tubo-ovarian  pedicle  (Ede- 
bohls). 

Pathological  Conditions  Other  than  Inflammation 
Affecting  the  Vermiform  Appendix. — For  the  sake 
of  completeness  I  append  a  list  of  various  diseased 
conditions  of  the  appendix  other  than  inflammatory, 
which  I  have  found  recorded  in  the  literature:  Pro- 
lapse of  mucous  membrane  of  appendix  (Rolleston^""); 
invagination   of  appendix  (^McKidd  '^'^)  •,  intussuscep- 


TO 


tion  of  the  appendix  (McGraw,"^"  Wright  and  Ren- 
shaw,^''  Waterhouse"')  ;  cystic  dilatation  of  appendix 
(Gruber/''' Slioemaker/-^'  Hawkins/^'  Coats");  reten- 
tion cyst  of  appendix  (Maylard,'^''  Sonnenburg^'^-') ; 
mucocele  of  appendix  (Fe're,'"  Vimont,""""  Baillet  ")  ; 
hydrops  of  vermiform  appendix  (Combemarle,"''  Gutt- 
mann,""  Ribbert  ^^') ;  tuberculosis  of  appendix  (Apert '" 
and  numerous  others) ;  echinococcus  of  appendix 
(Bierhof,^^  Birch-Hirschfeld ");  actinomycosis  of 
appendix  (Ekehorn,'"°  Gangolph  and  Duplant/^^ 
Czerny^^);  cystic  degeneration  or  alveolar  carcinoma 
of  appendix  (Rokitansky'^'"^);  primary  colloid  cancer 
of  appendix  (Draper^") ;  primary  cancer  of  appendix 
(Mosse  and  Daunic^^');  cancer  of  appendix  (Stim- 
son"^") ;  primary  adenocarcinoma  of  appendix 
(Wright  "^) ;  primary  endothelial  sarcomata  of  appen- 
dix (Glazebrook  '''). 

Bacteriology  of  the  Appendix. — Clarke"  has  felic- 
itously entitled  the  appendix  a  culture  tube.  Since 
Adenot  ^  and  Gouillioud,""  in  1891,  began  the  study  of 
the  bacteriology  of  the  appendix  and  showed  appendi- 
citis to  be  due,  in  practically  every  case,  to  bacterial 
invasion  of  the  appendix  walls,  most  frequently  by  the 
bacterium  coli  commune,  researches  in  this  direction 
have  been  continued  with  uninterrupted  zeal  and  en- 
thusiasm   by  a    number  of   workers.     Ekehorn,'""   in 

1892,  proved  that  the  bacterium  coli  manifested  dif- 
erent  degrees  of  virulence  in  different  cases,  and  that 
it  is  present  in  every  form  of  appendicitis,  from  the 
catarrhal  onward.  Robb,"'^"  in  1892,  reported  a  case 
of  associated  streptococcus  infection  of  the  vermiform 
appendix    and    right    Fallopian    tube.     Morris,'^"*'*    in 

1893,  published  the  first  article  with  the  distinct  title, 
"Infectious  Appendicitis."'  Weir,""'"  in  1893,  found 
the  diplococcus  pneumonias  in  nearly  pure  culture  in 
the  appendix  in  a  case  of  purulent  appendicitis,  and 
Ohlmacher,""  in  the  same  year,  found  the  proteus  vul- 
garis.    Hodenpyl,'^'   in   1893,  contributed  a  most  im- 


I  T 


portant  bacteriological  study  of  appendicitis  based 
upon  an  examination  of  thirty-five  cases.  Achard  and 
Broca/  in  1897,  presented  a  noteworthy  resume  of  the 
bacteria  found  in  the  peritoneal  exudate  in  twenty 
cases  of  appendicitis.  Beaussenat"  has  given  us  the 
most  important  paper  on  experimental  appendicitis. 
His  experiments,  supplemented  by  those  of  Josue',''* 
prove  that  germs  may  invade  the  lymphoid  tissue  of 
the  appendix  by  way  of  the  blood  and  by  way  of  the 
lymphatics,  as  well  as  through  the  mucous  membrane. 
Hartmann  and  Reymond  '^"  report  an  observation  of 
the  passage  of  the  bacterium  coli  from  an  appendix 
abscess  through  the  intact  bladder  wall,  causing  infec- 
tious cystitis. 

Complications  of  Appendicitis. — The  complications 
of  appendicitis  are  impressive  by  reason  of  both  their 
number  and  their  gravity.  Mortier,^"  Little,"""  Shef- 
fey,'''  Bennett,"  Lincoln,'"*^  Perry,-'^'  Andrews,^'  Pi- 
tres,"'  Hendricks,^''  Englisch,'^*^  Dale,'*  Bierhof,'' 
Murray,"^  Weiss,^®'^  and  Morris-'"  have  recorded  cases 
of  intestinal  strangulation,  the  result  of  appendicitis. 
Death  from  hemorrhage  has  resulted  from  perforative 
ulceration,  due  to  appendicitis,  (a)  of  the  small  in- 
testine (Osier''")  ;  (^)  of  the  sigmoid  (Stedman^'=^)  ;  (c) 
of  the  right  external  iliac  artery  (Powell, '^'^  Sour- 
dille'");  {d)  of  the  right  iliac  vein  (Fowler,'"* 
Lewis""') . 

Other  complications  or  sequelce  noted  are:  Pro- 
lapse of  the  mucous  membrane  of  the  appendix  into  the 
caecum  (Rolleston^"") ;  invagination  of  the  appendix 
(McKidd  ""') ;  discharge  of  the  gangrenous  appendix 
per  rectum.  (Jackson,^"  Long"'") ;  faecal  fistula  (Long,"" 
Rioblanc,"'  and  numerous  others') ;  appendiculo-intes- 
tinal  fistula  through  a  suppurating  mesenteric  gland 
(Packard"^');  vesico-intestinal  fistula  (Keen''");  per- 
foration of  the  colon,  rectum,  and  bladder  (Roches- 
ter^'') ;  perforation  of  the  bladder  (Clark,'"  Boardman,'" 
Cameron") ;  perforation  into  the  bladder  with  forma- 


12 


tion  of  stone  (Fowler''^^) ;  localized  and  general  peri- 
tonitis, by  almost  every  writer;  obliteration  of  the 
right  crural  artery  by  arteritis  (Be'rard  "'■')  ;  embolism 
of  the  left  anterior  tibial  artery,  with  gangrene  of  the 
leg  (Scheibenzuber^'') ;  embolism  of  the  pulmonary 
artery  (McGregor) ;  phlebitis  of  the  right  iliac-,  phle- 
bitis of  the  left  leg  (Freeman'");  thrombosis  of  the 
right  femoral  vein  (Legg''"*^) ;  phlebitis  and  thrombosis 
of  the  vena  mesenterica  magna  and  portal  pylephlebitis 
(Aufrecht,"  Ssawostjc^n' w'*^") ;  purulent  inflammation 
of  the  portal  vein  (Bacrnhoff,'^'  Moers,"^  Machell,'^* 
Mynter,*"^  Carless^^);  portal  pylephlebitis  and  hepatic 
abscess  (Traube,^"  Pierson,'''  Davat,'"  Boussi,'"  Jo- 
rand  ''") ;  hepatic  abscess,  "  la  foie  appendiculaire  ^'  of 
Dieulafoy'^'  (Krakowitzer,'^=^  Ashby,''  De  Gennes,^' 
Shoemaker,'"  Harte,""  Achard,' Nuding,'^"  Pillietand 
Costes,''"  Sheen, ^'^  Morton"^'');  left  perinephritic  ab- 
scess, perforation  of  the  diaphragm,  left  purulent  pleu- 
ritis  (Coats"^)  ;  right  perinephritic  abscess,  perforation 
of  the  diaphragm,  right  empyema  (Ardouard,"  Shiels,^''"* 
Rioblanc^''^) ;  the  same,  with  perforation  of  the  lung 
(Thacher^");  the  same,  with  gangrene  of  the  lung 
(Mader-'^) ;  right  pleuro-pneumonia  (Dupre  "*)  ;  sub- 
phrenic abscess  (Sachs,'"  Freiberg'"*);  perforation  of 
the  eighth  intercostal  space  and  right  lung  (McCal- 
lum,""'  McPhaedran'"'"") ;  purulent  cystitis,  due  to  mi- 
gration of  the  bacterium  coli  commune  through  the 
intact  bladder  wall  (Hartmann  and  Reymond  '"")  ;  pre- 
vesical abscess  (Tuffier^^');  ureteritis,  pyelonephritis 
(Hectoen'")  ;  scrotal  abscess  and  purulent  pleuritis 
(Lemariey"*');  multiple  distant  abscesses  (Pirard^^'); 
glycosuria  (Leidy'^'')  ;  fusion  of  the  appendix  to  the 
gall  bladder  (Czerny,"  Edebohls).  Beurnier,^*'  Czer- 
ny,'"  and  Shoemaker^"^"  have  devoted  special  attention 
to  the  coexistence  of  appendicitis  and  membranous 
colitis. 

Herniae    Containing  the  Appendix. — The  appen- 
dix   has  frequently   been  found  among  the  contents 


13 

of  a  hernial  sac.  Landsberg,"^  Hall,"^  Zdekauer,"' 
Monks,-"^  Ohlmacher,'"^  Kayser/^*  and  Gross"'  have 
recorded  cases  of  inguinal  hernia  containing  the  ap- 
pendix. The  case  of  Hall  is  historical  from  the  fact 
that  it  represents  the  first  removal  of  the  appendix 
with  survival  of  the  patient.  Landsberg,'^'  Polios- 
son, "\  Rotter,'"'  Routier,'"'  Ginnard,'^"  and  Vander- 
yggj.a47bis  have  found  the  appendix  as  part  of  the  con- 
tents of  a  femoral  hernia. 

Appendicitis  Associated  with  Diseased  Conditions 
of  the  Pelvic  Organs. — The  association  of  an  inflamed 
appendix  with  every  variety  of  diseased  conditions  of 
the  pelvic  organs,  more  especially  of  women,  is  a  mat- 
ter of  almost  daily  observation  in  the  practice  of  ab- 
dominal surgery.  In  some  cases  the  appendix  is  the 
starting-point  of  the  diseased  action,  in  others  it  be- 
comes involved  secondarily  to  disease  affecting  pri- 
marily the  pelvic  viscera.  Baldy,"  Richelot,'"'  Mix- 
ter"\  Robb,"-"  Jr^ggard,""  Binckley,'"  McGuire,'-'*'  and 
Deaver'^'  have,  among  others,  given  special  attention 
in  their  writings  to  this  aspect  of  our  subject. 

Appendicitis  Complicating  Pregnancy,  Labor,  and 
the  Puerperal  State. — The  classical  case  of  Mesti- 
vier,"^  the  first  in  which  a  diseased  appendix,  in  this 
case  containing  a  pin,  was  recognized  at  autopsy  as 
the  cause  of  an  abscess  in  the  right  iliac  fossa,  oc- 
curred in  a  woman  eight  months  pregnant.  The  case 
of  Hancock,'"^  no  less  historical  as  representing  the 
first  successful  operation  for  deep-seated  perityphlitic 
abscess,  also  occurred  in  a  woman  eight  months  preg- 
nant. The  patieni  miscarried  four  days  after  opera- 
tion. The  next  case  recorded  is  that  of  Porcher,"" 
whose  patient  miscarried  at  five  months,  died  suddenly 
and  unexpectedly  fourteen  hours  afterward,  and  was 
found  on  post-mortem  to  have  purulent  appendicitis 
and  peritonitis.  Hirst,'^®  in  1890,  operated  upon  a 
woman  six  months  pregnant  for  supposed  acute  sup- 
purative appendicitis.     He  found  chronic  appendicitis 


14 

with  a  few  adhesions.  The  patient  died  two  days 
after  the  operation ;  there  was  no  autopsy.  Mixter,"* 
in  1 89 1,  reports  a  case  of  appendicitis  originating  in 
the  seventh  month  of  pregnancy;  successful  operation 
was  performed  two  months  after  the  termination  of 
pregnancy.  Wigging"  in  1892,  reports  an  autopsy 
upon  a  woman  three  months  pregnant,  who  died  ls  the 
result  of  perforative  appendicitis.  Petersen,"'  in 
1893,  records  a  case  of  appendicitis  on  the  seventh 
day  following  a  l?hor  at  term,  with  rupture  of  the  ab- 
scess into  the  bowel  and  recovery  without  operation. 
Krafft  ""^  reports  a  successful  operation  for  purulent  ap- 
pendicitis, performed  January  29,  1893,  upon  a  woman 
aged  twenty-five  years,  four  and  a  half  months  advanced 
in  pregnancy.  The  patient  had  double  pleuritis  and 
acute  endocarditis  immediately  preceding  the  appen- 
dicitis. The  pregnancy  proceeded  to  term  without 
interruption,  and  terminated  in  the  birth  of  a  boy 
whom  the  mother,  in  memory  of  her  experience,  chris- 
tened Malgretout.  Grandin,'"  in  1893,  reports  a  case 
of  acute  catarrhal  appendicitis  six  days  after  delivery 
at  term ;  recovery  without  operation.  Also  a  case  of 
miscarriage  at  three  months  complicated  with  acute 
catarrhal  appendicitis.  Munde,""  in  1894,  reports  the 
successful  evr,,:uation  of  a  peri-appendicular  abscess  in 
a  woman  eight  months  pregnant.  A  dead  child  was 
born  one  week  after  operation. 

From  this  time  onward  reports  of  cases  of  appendi- 
citis occurring  in  pregnant  women  become  more  numer- 
ous. Hind,'"^  in  1895,  reports  a  case  having  medico- 
legal bearings.  A  woman,  pregnant  near  term,  was 
violently  assaulted.  Labor  set  in,  and  death  followed 
two  days  after  delivery.  Autopsy  showed  an  abscess 
due  to  perforation  of  the  appendix.  Bayley,^^  in  the 
same  year,  records  an  attack  of  appendicitis  during  the 
sixth  month  of  pregnancy;  recovery  took  place  without 
operation,  followed  by  delivery  at  term.  McArthur,^"^ 
also  in  1895,  reports  two  operations  for  acute  appen- 


15 

dicitis  in  pregnant  ^vomen,  both  fatal.  Johnson/^*  in 
1896,  reports  a  successful  operation  for  non-suppura- 
tive  appendicitis  in  a  woman  three  and  a  half  months 
pregnant,  followed  by  confinement  at  term.  Robson,*"' 
in  the  same  year,  records  a  successful  operation  for 
appendicitis  thirty-six  hours  after  accouchement  at  the 
eighth  month.  McCosh,"-^  in  1S97,  reports  a  success- 
ful operation  for  appendicitis  during  the  sixth  month 
of  pregnancy,  with  subsequent  delivery  at  term.  Abra- 
hams," in  1897,  collected  the  more  recent  cases  of  ap- 
pendicitis during  pregnancy  from  the  literature,  giving 
cases  of  his  own  together  with  additional  cases  of 
Munde,  Harrison,  Thomason,  Crutcher,  and  Hirst. 
For  details  of  these  the  reader  is  referred  to  the  de- 
scriptions and  abstracts  of  Abrahams,  Deaver,'^*  in 
1S9S,  wrote  a  valuable  paper  on  appendicitis  in  rela- 
tion to  disease  of  the  uterine  adnexa  and  pregnancy. 
Finally  Gerster,'^'  in  1899,  contributes  three  personal 
observations  of  appendicitis  successfully  operated  upon 
during  the  eighth,  second,  and  fifth  months,  respec- 
tively, of  pregnancy,  with  premature  labor  in  the  first 
and  delivery  at  term  in  the  second  and  third  cases. 

The  Diagnosis  of  Appeudicitis. — The  symptoms 
and  signs  of  perityphlitic  abscess^  especially  in  the 
later  stages  of  the  disease,  have  been  pretty  clearly  un- 
derstood by  the  profession  ever  since  the  time  of  Mes- 
tivier.  Beginning  with  1S47,  the  diagnosis  of  perfora- 
tion of  the  appendix,  or  of  its  involvement  in  the  in-, 
flammatory  process,  began  to  be  made  more  frequently, 
among  the  first  by  Cless"'  and  Hancock.*"  Gibney,'^^ 
in  1 88 1,  wrote  a  very  creditable  paper  on  the  differ- 
ential diagnosis  between  appendicitis  and  hip-joint 
disease.  Valuable  modern  contributions  have  been 
presented  by  Morton,'''  Deaver,'"  Meek,-'"  Fowler,'"'^ 
Murphy ,'"''  and  numerous  others.  Fowler*'^'^  has  gone 
very  fully  into  the  differential  diagnosis  of  appendi- 
citis in  the  female. 

The  greatest  advance  in  the  diagnosis  of  acute  ap- 


i6 


pendicitis  v/e  owe  to  the  keen  observations  of  McBur- 
ney,^*^  which,  in  1889,  gave  us  that  valuable  aid  in 
diagnosis  now  known  the  world  over  as  "the  McBur- 
ney  point."  Rosenthal  ^"  makes  a  weak  priority  claim 
for  Traube  in  relation  to  the  discovery  of  the  point. 

The  elaboration  and  publication  by  Edebohls,®^  in 
1894,  of  his  method  of  palpation  of  the  vermiform 
appendix  finally  made  those  who  have  become  con- 
versant with  the  method  masters  of  the  situation  as 
regards  the  diagnosis  of  both  acute  and  chronic  appen- 
dicitis. It  is  true  a  thickened,  inflamed  appendix  had 
previously  now  and  then  been  felt  through  the  ab- 
dominal walls.  Treves,^"  in  1889,  and  Cameron, ^^  in 
1893,  each  reported  such  an  experience,  and  Duncan,^' 
in  J892,  says  that  the  position  of  an  inflamed  appen- 
dix may  often  be  felt.  The  positive  determination  of 
the  health  or  otherwise  of  the  appendix,  however,  by 
direct  examination  and  palpation  of  the  organ  in  each 
and  every  case  presenting,  was  considered  an  impossi- 
bility and  never  attempted  previous  to  the  publication 
of  Edebohls. 

Among  those  who  have  adopted  Edebohls'  method 
of  palpation  of  the  appendix,  and  who  depend  upon  it 
for  the  diagnosis  of  appendicitis,  may  be  mentioned 
Deaver,'«  Long,'^"  Halsted,^''  Shrady,'''  Morris,"" 
Noble,'''  Mynter,""  Murphy,  Beck,"  and  Kelly.'" 

The  Medical  Treatment  of  Appendicitis. — Vol- 
umes have  been  written  upon  the  medical  and  surgical 
treatment  of  appendicitis.  The  history  of  the  origin 
and  development  of  the  surgical  treatment  of  the  affec- 
tion will  receive  attention  presently.  The  medical 
treatment  has  received  full  consideration  at  the  hands 
of  all  the  older  and  many  of  the  more  recent  clinicians, 
and  the  principles  supposed  to  underlie  it  are  well 
known  to  every  practitioner.  Few  physicians  advo- 
cate, with  With, ^"  medical  treatment  only  for  all  cases. 
A  large  number  of  prominent  internists,  with  Eliot,'" 
Fitz,""  and  others,  consider  appendicitis  essentially  a 


I? 


surgical  affection.  As  Ipng  ago  as  1848,  Smith  ^^^  ex- 
pressed doubt  as  to  the  efficacy  of  all  local  applica- 
tions, including  leeches,  saying  of  the  latter:  "If  you 
are  going  to  use  leeches  in  typhlitis  apply  them  at  the 
anus,  not  over  the  swelling."  The  only  recommenda- 
tion of  electricity  in  the  treatment  of  appendicitis  is 
by  Williams.''' 

The  Surgical  Treatment  of  Appendicitis. — The 
earliest  recorded  case  of  operation  for  appendicitis  is 
generally  credited  to  Mestivier,"^"^  who,  in  1759,  incised 
and  drained  an  abscess  in  the  right  inguinal  region. 
The  patient  died,  and  the  autopsy  disclosed  an  appen- 
dix perforated  by  a  pin.  A  few  operations  for  so- 
called  perityphlitic  abscess,  which  had  slowly  per- 
forated the  abdominal  parietes  and  become,  in  part  at 
least,  subcutaneous,  were  reported  between  1759  and 
1848.  Dupuytren'^  operated  thus  in  1815  and  1828; 
Ahrt**  in  1832,  and  Parker"""  in  1843.  ^^-  ^^^  o^-  these 
cases  fluctuation  was  distinctly  made  out,  and  pus  was 
encountered  in  the  subcutaneous  tissues  of  the  abdom- 
inal wall. 

Hancock,'"  on  April  17,  1848,  performed  the  first 
deliberate  operation  for  deep-seated  suppuration  of 
appendicular  origin.  He  operated  on  the  fifteenth  day 
of  illness,  and  before  fluctuation  became  apparent, 
reaching  the  pus  collectiqn  by  a  font-inch  incision 
extending  from  just  above  the  right  anterior  superior 
spine  of  the  ilium  downward  and  inward  along  Pou- 
part's  ligament.  His  patient  recovered.  On  the 
strength  of  this  case  Hancock  proposed  to  operate 
early  in  these  cases  before  fluctuation  appeared,  re- 
marking that  patients  do  not  usually  live  to  fluctua- 
tion. His  teaching,  however,  found  no  echo  in  medi- 
cal literature  until  reiterated  by  Lewis'""^  in  1856. 
His  example  was  first  imitated  after  eighteen  years  by 
Parker, ■■*''■  the  publication  of  whose  case,  in  1867,  may 
fairly  be  said  to  have  directly  inaugurated  the  modern 
surgical  treatment  of  abscesses  of  appendicular  origin, 


i8 


and  indirectly  to  have  led  to  the  modern  surgery  of  the 
appendix. 

By  many  writers  Parker  is  credited  with  the  first 
operation  for  perityphlitic  abscess  in  1843.  Parker, 
in  1867,  reported  four  cases  of  perityphlitic  abscess 
operated  upon,  the  first  operation  being  performed  in 
1843.  In  his  first  three  cases,  however,  subcutaneous 
fluctuation  or  phlegmon  invited  the  incision,  as  it  had 
done  in  the  cases  already  cited  as  previously  reported. 
Parker's  first  operation  for  deep-seated  suppuration, 
prior  to  fluctuation,  was  performed  in  1866,  nearly 
eighteen  years  after  the  original  operation  of  Hancock. 
His  patient  also  recovered. 

From  1867  to  1884  the  initiative  taken  by  Hancock 
and  Parker  in  opening  and  draining  so-called  peri- 
typhlitic abscesses  before  fluctuation  was  evident  was 
enthusiastically  taken  up  and  followed,  especially  by 
American  surgeons.  New  York  being  at  first  the  chief 
focus  of  the  new  surgical  activity.  Buck,  Sands, 
Weber,  Bontecou,  Burge,  Whitall,  Ward,  Kelsey,  Hol- 
den,  Clarke,  Ely,  Raub,  Bacon,  Clay,  North,  Beach, 
Chamberlain,  Koehler,  Mynter,  Weir,  Byrd,  Pierson, 
were  among  the  earliest  performers  or  reporters  of 
operations  for  the  evacuation  of  deeply  seated  abscesses 
of  appendicular  origin.  Noyes,'"  in  1883,  collected 
the  reports  of  one  hundred  operations  for  perityphlitic 
abscess. 

Nearly  all  of  the  perityphlitic  abscesses  operated 
upon  during  this  period  were  opened  by  the  original 
classical  incision  of  Hancock.  Weber^^^  at  first  con- 
tented himself  with  incising  down  to,  but  not  through, 
the  fascia  transversalis,  and  this  method  was  even 
advocated  as  the  routine  procedure  by  Whitall. '"^^ 
Kolb,""^  in  i860,  practised  puncture  of  the  abscess  by 
the  trocar  and  dilatation  of  the  opening  with  sponge 
tents.  Muenchmeyer,^"  in  i860,  was  the  first  to  prac- 
tise a  counter-opening  in  the  loin  to  obtain  better 
drainage,  a  procedure  which  has  since  found   many 


19 

imitators.  Buck/^  in  1861,  evacuated  a  pelvic  ab- 
scess, presumably  of  appendicular  origin,  by  puncture 
through  the  rectum.  Bartholow,''  in  1866,  credits 
Buck  with  approaching  a  pentyphlitic  abscess  from 
beneath  Poupart's  ligament  by  an  incision  carried 
through  the  fascia  lata  of  the  right  thigh,  thence  work- 
ing his  way  upward  beneath  Poupart's  ligament  to  the 
abdomen.  I  have  been  unable  to  find  the  original 
account  by  Buck  of  this  procedure.  Barlow  and  God- 
lee,*"  in  1885,  operated  upon  a  case  of  appendicular 
abscess  by  two  incisions,  one  median,  exploratory  in 
character,  and  one  lateral,  over  the  abscess,  to  evacu- 
ate the  pus.  This  procedure  has  been  followed  in  a 
number  of  cases  by  various  operators.  Kroenlein,"^ 
in  1887,  reported  the  first  case  of  operation  for  peri- 
typhlitic  abscess  under  Listerism.  Homans,'^''  in  1886, 
took  a  decided  step  in  advance  in  the  case  of  an  ap- 
pendicular abscess  deeply  situated  against  the  pos- 
terior abdominal  wall.  He  opened  the  abdomen 
through  the  usual  incision  above  and  parallel  to  Pou- 
part's ligament,  and  evacuated  the  abscess  across  the 
free  peritoneal  cavity  while  protecting  the  latter  against 
infection  by  suitably  placed  packing.  This  has  be- 
come and  remained  standard  modern  practice.  Not 
so  the  procedure  of  Edebohls,''^  who  in  1889,  in  a 
similar  case,  closed  the  peritoneum  by  suture,  dissected 
it  up,  and  opened  the  abscess  retroperitoneally. 
Byrd,'*  in  1881,  in  a  case  of  perforative  appendicitis 
with  two  additional,  ulcerative  perforations  of  the 
caecum,  adopted  the  procedure,  nothing  less  than  bril- 
liant for  that  day,  of  converting  the  three  openings 
into  one  large  one,  establishing  an  artificial  anus  by 
stitching  the  bowel  opening  to  the  wound,  and  irri- 
gating and  draining  the  free  peritoneal  cavity.  His 
patient  recovered.  Mention  should,  finally,  be  made 
of  Kottmann's'"'  plan  of  opening  the  abscess  by 
Vienna  paste,  the  only  advocacy  or  practice  of  this 
method  which  I  have  found  recorded  in  the  literature. 


20 


The  above  data  all  refer  to  operations  for  the  evacu- 
ation of  perityphlitic  abscesses  of  appendicular  origin 
undertaken  before  the  time  at  which  operations  upon 
the  appendix  itself  came  into  vogue.  The  history  of 
the  surgery  Df  the  appendix  itself,  and  data  in  connec- 
tion therewith,  will  presently  receive  attention.  Be- 
fore proceeding  to  this  chapter  of  the  history  of  ap- 
pendicitis, however,  two  subjects,  that  of  aspiration, 
exploratory  or  curative,  of  perityphlitic  abscesses,  and 
that  of  so-called  left-sided  appendicitis,  deserve  a  mo- 
ment's consideration. 

Exploratory  Puncture. — Bontecou,"'  in  1873,"  re- 
ported two  cases  of  operation  for  perityphlitic  abscess 
in  which  he  employed  previous  aspiration  to  determine 
the  presence  of  pus.  Prior  to  that  time  we  find  re- 
corded, now  and  then,  a  crude  attempt  to  establish  the 
presence  of  pus  by  an  oblique  puncture  with  a  narrow 
knife,  a  grooved  needle,  or  a  trocar.  Potter, -^'^  in  1879, 
reported  a  cure  of  perityphlitic  abscess  following  a 
single  aspiration  of  the  contained  pus.  Peltzer,'*''^  in 
1882,  observed  a  cure  following  two  aspirations  of  the 
pus,  followed  each  time  by  irrigation  of  the  abscess 
cavity  with  a  solution  of  salicylic  acid.  Bull,^*^  in 
1886,  advocates  dropping  all  time  limits  and  operating 
as  soon  as  pus  can  be  discovered  by  the  needle.  At 
about  this  period  exploratory  punctures  for  diagnostic 
purposes  were  much  in  vogue.  Gradually,  however, 
they  yielded  place  to  the  increasing  positiveness  with 
which  diagnosis  could  be  reached  without  their  aid, 
until  at  the  present  day  probably  no  surgeon  of  any 
prominence  either  employs  or  recommends  the  needle 
for  diagnosis. 

Left-Sided  Appendicitis. — As  regards  ieft-sided 
appendicitis  the  only  genuine  case  thereof  on  record 
is  that  of  Biegi,^^  which  occurred  in  a  soldier  who 
died  of  appendicitis  and  was  found  on  autopsy  to  have 
a  complete  transposition  of  all  the  viscera.  The  case 
of  Bontecou/'  in  which  death  resulted  from  ulcerative 


21 


perforation  of  the  small  intestine  into  the  left  iliac 
fossa;  that  of  Traube,^^^  of  a  perityphlitic  abscess 
pointing  on  the  left  side;  and  the  three  cases  reported 
by  Fowler/''^  in  which  the  caecum  and  appendix  were 
displaced  to  the  left,  all  originated  primarily  in  the 
right  iliac  fossa.  So  did  the  case  of  Coats/^  in  which 
empyema  of  the  left  chest  followed  perforation  of  the 
diaphragm  by  pus  from  an  abscess  of  appendicular 
origin. 

Surgery  of  the  Appendix. — We  have  finished  with 
the  history  of  the  era  when  operations  for  the  evacua- 
tion and  drainage  of  perityphlitic  abscesses  consti- 
tuted, with  the  few  exceptions  mentioned,  the  sole  surgi- 
cal resource  in  the  treatment  of  appendicitis,  or  rather 
of  its  results.  We  come  now  to  the  period  which  saw 
the  birth  of  the  surgery  proper  of  the  appendix  itself. 
We  will  consider  the  surgery  of  the  appendix  as  ap- 
plied, first,  to  the  treatment  of  acute  appendicitis,  and, 
secondly,  to  the  treatment  of  chronic,  relapsing,  and 
interval  cases. 

The  first  recorded  operation  upon  the  appendix  itself 
was  planned  by  Dr.  Mahomed  and  executed  on  August 
24,  1883,  by  Symonds.""  Mahomed  diagnosticated  a 
stone  in  the  appendix.  Symonds  removed  the  stone, 
three-fourths  by  one-half  inch  in  size,  through  the 
ordinary  incision  for  tying  the  external  iliac  artery, 
approaching  the  appendix  from  behind,  through  peri- 
toneal adhesions,  opening  the  appendix,  extracting  the 
stone,  and  closing  the  opening  in  the  appendix  by 
Lembert  sutures.  The  patient  recovered  and  was 
cured  of  all  his  s.ymptoms.  In  connection  with  this 
case  Symonds  becomes  prophetic  in  relation  to  the 
future  removal  of  the  appendix  in  similar  cases.  I 
have  found  but  three  other  instances  of  operation  upon 
the  appendix  stopping  short  of  its  removal.  INIorton,'*'^ 
on  April  27,  1887,  removed  the  larger  part  of  an  appen- 
dix containing  a  perforation,  between  two  ligatures, 
one  applied  near  the  base  and  one  near  the  distal  free 


341 


22 


end  of  the  appendix.      Sands, ^°^  on  December  31,  1887 
closed  a  perforation  of  the  appendix  by  suture.     Tait 
in  1889,  slit  open  and  drained  an  appendix.     All  three 
patients  recovered. 

Excision  of  the  Appendix. — Kroenlein,''*  on  Feb- 
ruary T4,  1884,  performed  the  first  removal  of  the  ap- 
pendix for  acute  appendicitis.  He  was  followed  in 
1886  by  Weir,'"'  Bryant,^'  and  one  or  two  others. 
These  earliest  appendicectomies  for  acute  appendicitis 
had  one  discouraging  feature  in  common;  they  were 
all  fatal. 

The  first  successful  removal  cf  the  appendix  was 
performed  by  Hall,'"  on  May  8,  1886,  in  an  operation 
for  the  relief  of  a  strangulated  hernia.  The  appendix, 
with  an  abscess  around  it,  was  found  among  the  con- 
tents of  the  hernial  sac,  tied  off,  and  removed. 

Morton,'^-  on  March  19,  1888,  and  Sands,^°^  on 
April  17,  1888,  performed  the  first  successful  appen- 
dicectomies for  acute  appendicitis,  the  correct  diag- 
nosis having  been  made  in  both  cases  before  operation. 
To  Morton  belongs  priority  of  performance,  to  Sands 
priority  of  publication.  Other  successful  appendicec- 
tomies for  acute  appendicitis  were  performed  during 
1888,  in  the  order  named,  by  Hoffmann,'^'*  McBur- 
ney,""  Cutler,"  and  VVeir.^*^'  Hoffmann  removed  the 
appendix  through  a  median  incision,  and  the  case  of 
McBurney  was  the  first  in  which  an  acutely  inflamed 
appendix,  full  of  pus,  was  removed  entire  and  without 
rupture. 

Thereafter  removal  of  the  appendix  in  acute  appen- 
dicitis rapidly  became  a  recognized  and  oft-undertaken 
procedure.  As  early  as  1889,  McBurney'"'^  reported 
seven  appendicectomies  of  his  own  with  six  recoveries 
and  one  death,  and  Morton'""  four  appendicectomies 
with  two  recoveries  and  two  deaths.  Since  that  time 
scores  of  operators  number  their  appendicectomies  for 
acute  appendicitis  by  the  hundreds. 

Treves,'*'  on  June  29,  1888,  performed  the  first  ap- 


23 

pendicectomy  for  relapsing  appendicitis.  The  opera- 
tion as  described  would  be  classed  as  modern  even  at 
this  day,  the  stump  end  being  closed  by  suture  instead 
of  ligated,  the  abdominal  wall  closed  for  primary 
union,  and  the  patient  recovering.  The  rapidity  with 
which  operations  for  relapsing  appendicitis,  or  inter- 
val operations,  were  adopted,  and  the  success  with 
which  they  were  practised  by  surgeons  the  world  over, 
are  best  evidenced  by  the  fact  that  Bull,"  as  early  as 
1894,  was  able  to  collect  four  hundred  and  forty-four 
interval  operations  with  eight  deaths.  It  is  safe  to 
say  that  at  the  present  day  several  thousand  such  cases 
could  be  collected  from  the  literature  alone. 

The  Technics  of  Appendicectomy. — The  various 
surgical  procedures  for  the  simple  evacuation  and 
drainage  of  a  peri-appendicular  abscess  have  already 
been  considered.  It  remains  to  record  the  history  of 
the  development  of  the  technics  of  the  operation  for 
the  removal  of  the  appendix. 

Appendicectomy  for  Acute  Perforative  or  Gan- 
grenous Appendicitis. — During  the  two  or  three  years 
immediately  following  the  first  removal  of  the  appen- 
dix for  acute  perforative  appendicitis  by  Kroenlein,"* 
in  1884,  and  the  early,  equally  unsuccessful  imitations 
of  his  example,  the  advocates  of  appendicectomy  in 
pus  cases  were  few  indeed.  The  first  successful  cases, 
reported  in  1888,  furnished  a  new  stimulus  to  surgical 
activity  in  this  direction,  and  within  two  or  three 
years  thereafter  the  number  of  cases  reported  slowly 
increased.  Since  1890  the  large  majority  of  surgeons 
with  a  name  advocate  removal  of  the  appendix  in  acute 
appendicitis  as  the  routine  procedure,  always  to  be 
attempted  save  under  m.ost  exceptional  conditions.  A 
few  surgeons  claim  that  it  is  always  both  possible  and 
better  to  remove  the  appendix  in  acute  appendicitis. 
This  advice  and  practice  are  based  upon  the  fact  that 
a  second  operation  for  appendicitis  has  become  neces- 
sary in  some  cases  in  which  the  appendix  was  left  at 


24 


the  first  operation.  Comparatively,  however,  the  cases 
in  which  such  a  secondary  operation  was  called  for  or 
performed  are  very  few,  Morton,'"  Patel,'"'  Romans,"^" 
and  Wolf  ^''"*  among  others  have  put  on  record  such  sec- 
ondary onerations.  The  expedient  adopted  by  Wyeth  "* 
of  operating  at  two  sittings  represents  an  unnecessary 
compromise. 

In  direct  opposition  to  the  modern  tendency  to  re- 
move the  appendix  whenever  feasible,  and  vainly 
attempting  to  stem  the  tide,  we  find  Barton,''^  as  late 
as  1894,  and  a  few  others  even  more  recently,  preach- 
ing the  doctrine  of  leaving  the  appendix  in  operations 
for  acute  appendicitis,  claiming  better  results  from  this 
practice.  That  this  claim  does  not  hold  good  in  the 
work  of  the  better  operators  goes  without  saying. 

The  Incision  in  Acute  Appendicitis. — The  early 
incisions  employed  in  operations  for  acute  appendi- 
citis, when  abscesses  were  emptied  and  drained 
<{)nly,  as  well  as  when  the  appendix  was  removed, 
always  divided  all  the  various  anatomical  layers  of 
the  abdominal  wall  in  one  and  the  same  directions: 
either  a  little  above  and  parallel  to  Poupart's  liga- 
ment, or  nearly  vertically,  just  external  and  parallel 
to  the  outer  border  of  the  right  rectus  abdominis  mus- 
cle. Aside  from  the  counter-opening  in  the  back  more 
or  less  frequently  practised  by  a  number  of  surgeons, 
Dejace  "^  in  one  case  practised  lumbar  incision  of  a 
perityphlitic  abscess,  and  Gerster'^°  speaks  of  Lange 
as  in  one  instance  having  to  abstain  from  removing 
the  appendix  through  an  anterior  incision,  later  on 
removing  the  organ  successfully  through  a  posterior 
wound.  Vischer,'°°  in  1897,  proposed  a  new  site  for 
the  incision,  placing  it  above  and  parallel  to  the  iliac 
crest  and  running  from  the  outer  edge  of  tlie  external 
oblique  inward  to  the  anterior  superior  iliac  spine. 
The  median  incision  has  also  been  practised,  now  and 
then,  by  Hoffmann'''  and  others,  but  has  found  no  en- 
thusiastic advocates. 


25 


The  gridiron  incision  of  McBurney,"-^  published  in 

1894,  represents  the  most  modern  thought  and  fully 
satisfactory  technics  in  regards  to  the  incision  of  the 
anterior  abdominal  wall  practised  anywhere  between 
the  outer  borders  of  the  recti  and  the  erector  spinae 
muscles  on  either  side,  not  only  for  appendicitis,  either 
acute  or  chronic,  but  also  for  other  intra-abdominal 
conditions  exceptionally  best  approached  within  the 
limits  stated.  McBurney  at  first  thought  his  incision 
unsuitable  for  pus  cases  calling  for  gauze  packing. 
This  judgment,  however,  has  been  reversed  by  the  fur- 
ther experience  of  a  number  of  American  operators, 
among  them  the  writer,  who  constantly  use  this  incision 
in  cases  of  acute  appendicitis,  and  consider  all  the  other 
incisions  already  mentioned  as  antiquated  and  out  of 
place  in  up-to-date  surgery.  The  slight  modification  of 
the  gridiron  incision  proposed  by  Elliot, ^^'^  who  cuts  the 
fascia  of  the  external  oblique  horizontally,  while  at- 
tempting to  refine  on  the  principle  enunciated  by  Mc- 
Burn"ey,  is  of  no  practical  importance. 

The  Incision  in  Chronic  Appendicitis. — The  com- 
ments made  anent  the  first  incisions  practised  for  acute 
appendicitis  hold  good  also  for  those  made  for  the 
removal  of  the  appendix  in  interval  cases,  with  this 
important  exception:  that,  beginning  with  the  very 
first  removal  of  the  appendix  for  recurrent  inflamma- 
tion by  Treves,  the  abdominal  wound  has  been  very 
generally  closed  for  primary  union  without  attempts  at 
drainage.  The  gridiron  incision,  originally  devised 
and  brought  forAvard  by  McBurney  for  cases  of  appen- 
dicitis not  requid_ng  drainage,  but  equally  applicable 
to  pus  cases,  represents  the  first  giant  stride  forward 
in  the  surgery  of  the  incision  made  for  the  removal  of 
the    appendix    in    chronic   appendicitis.     Battle, '''   in 

1895,  gave  us  the  incision  through  the  right  rectus 
abdominis  muscle,  which  in  chronic  appendicitis  has 
become  the  successful  rival  of  the  gridiron  incision  of 
McBurney.     The    rectus    incision  of    Battle    may  be 


26 


found  admirably  pictured  and  described  as  the  simple 
incision  by  Deaver'"  in  1896.  Curiously  enough,  in 
1897,  Jalaguier,'"*^  Kammerer,"'  and  Lennander''"  pub- 
lished the  Battle  incision,  each  apparently  urder  the 
impression  that  the  incision  was  original  with  himself. 
The  lumbar  incision  for  chronic  appendicitis  was 
brought  forward  by  Edebohls/""  in  1898,  as  applicable 
to  cases  in  which  right  nephropexy  and  appendicec- 
tomy  were  called  for  in  the  same  patient. 

About  ten  centimetres  seems  to  be  the  length  of  in- 
cision usually  accepted  as  required  in  acute  appendi- 
citis. In  the  surgery  of  chronic  appendicitis  Mor- 
ris,"°  in  1893,  first  recognized  that  such  long  incisions 
were  unnecessary,  and  loudly  called  for  the  one-and-a- 
half-inch  incision.  He  has  since  been  outdone  in  this 
direction  by  Scott, ^^*  who  writes  on  "the  incision  less 
than  one  and  a  half  inches  long  in  appendicitis." 
The  writer'"^  has  recently  recorded  his  views  on  the 
subject,  and  will  close  with  the  statement  that  the 
only  incisions  necessary  and  permissible  in  the  mod- 
ern surgery  of  the  appendix  are  the  gridiron  incision 
of  McBurney,  the  rectus  incision  of  Battle,  and,  per- 
haps, the  lumbar  incision  of  Edebohls. 

Technics  of  the  Stump. — The  treatment  of  the 
stump  left  after  amputation  of  the  appendix  has  occu- 
pied a  great  deal  of  the  attention  of  surgeons.  In 
some  cases  of  acute  appendicitis,  with  gangrenous  de- 
struction and  disintegration  of  the  entire  appendix  and 
even  of  greater  or  less  areas  of  the  csecal  walls,  the 
question  of  a  stump  and  its  treatment  does  not  arise. 
In  such  cases  the  damage  must  be  repaired  by  suture, 
and  the  danger  must  be  minimized  by  the  usual  gauze 
packing  and  drainage,  or  by  suture  of  the  damaged 
bowel  to  the  abdominal  wall  as  practised  by  Byrd,^'^ 
Bunner,"  and  others.  Simple  ligation  of  the  stump, 
though  still  very  generally  practised,  cannot  be  consid- 
ered a  perfectly  safe  procedure.  Dock  '^  has  put  on 
record  a   death  from  simple  ligation,  and  the  writer 


27 


knows  of  another  unpublished  case  in  which  intestinal 
leakage  and  fatal  peritonitis  followed  the  slipping  of 
a  ligature  placed  around  an  appendix  stump. 

The  example  of  Lautard/''^  who  amputated  the  tip 
of  the  appendix  and  sewed  the  long  stump  to  the  ab- 
dominal walls,  has  found  no  imitators. 

Invagination  of  the  ligated  stump  has  been  attempted 
by  Smith  '""  and  many  others  since  his  time.  All  such 
attempts  are  illogical  and  have  necessarily  met  with 
failure,  as  complete  invagination  of  a  ligated.  stump  is 
an  impossibility.  The  most  that  can  be  accomplished 
is  to  depress  a  ligated  stump  and  cover  it  over  with 
peritoneum,  a  procedure  which  Stimson^^^  was  the  first 
to  condemn  as  ''bottling  up"  of  the  appendix. 

Closure  of  the  open  ends  of  the  appendix  by  suture 
was  practised  by  Treves^^°  in  the  very  first  case  of  re- 
moval of  the  appendix  for  recurrent  appendicitis,  the 
mucous  and  muscular  coats  being  united  by  suture. 
Treves,  however^  found  it  impossible  in  his  case  to 
sew  the  peritoneum  over  the  free  end  of  the  stump, 
which  procedure  appears  to  have  been  first  accom- 
plished by  Allingham.  Monks,'"''  in  1890,  im.proved 
this  step  of  the  technique  by  first  inverting  the  cut 
end  of  the  appendix  and  then  closing  the  inverted  edge 
by  suture.  Ruth,^"''  in  1895,  sutured  the  cut  edges  of 
the  appendix  stump,  inverted  the  stump,  and  approxi- 
mated the  peritoneum  by  suture. 

Inversion  of  the  appendix  stump  without  previous 
ligation  and  suture  was  practised  by  Dawbarn'*^  as  far 
back  as  1890  or  1891.  The  correct  principle  underly- 
ing Dawbarn's  method  was  clumsily  imitated  by  Plum- 
mer,'^"^  who  slits  the  appendix  stump  upward  at  two 
opposite  points,  trims  and  inverts  the  flaps,  and  sutures 
the  serosa — and  by  Bloch,"  who  uses  a  temporary 
suture  through  the  lips  of  the  appendix  stump,  passes 
the  threaded  suture  through  the  csecal  wall  opposite 
the  appendix,  from  within  outward,  withdraws  the 
suture,  and  closes  the  peritoneum  over  the  inverted 
stump. 


28 


Price^"^  and  Eastman^^  do  away  entirely  with  a 
stump  by  excision  of  the  entire  appendix  and  suture 
of  the  resultant  hole  in  the  bowel  wall.  Edebohls^" 
originated  inversion  of  the  entire,  uncut  appendix,  the 
only  procedure  which  does  away  with  the  necessity  of 
opening  the  bowel  and  with  the  resultant  risk  of  infec- 
tion. His  procedure,  so  far  as  I  am  aware,  has  found 
but  one  imitator,  Fowler,'"^  whose  first  and  only  case 
of  inversion  of  the  entire  appendix  for  chronic  appen- 
dicitis ended  fatally  as  the  result  of  the  operation. 
Against  this,  however,  stand  considerably  more  than 
one  hundred  cases  of  inversion  of  the  entire,  uncut 
appendix  for  chronic  appendicitis,  at  my  own  hands, 
without  a  single  death. 

Septic  Peritonitis  ;  Drainage  ;  Accidents. — The 
treatment  of  the  diffuse  septic  peritonitis  accompany- 
ing appendicitis  has  received  attention  at  several 
hands.  McBurney,^"^  in  1895,  wrote  the  most  impor- 
tant clinical  contribution  to  this  aspect  of  appendicitis, 
advocating  free  flushing  of  the  peritoneum  with  drain- 
age, procedures  practised  by  Byrd  ^^  as  early  as  1881. 
Pond"'"  added  to  these  resources,  in  extremely  bad 
cases,  incision  of  the  intestine  and  suture  of  the  inci- 
sion lips  to  the  abdominal  wound,  permitting  of  the 
direct  introduction  of  salines,  stimulants,  etc.,  into 
the  intestine. 

Gauze  drainage  is  all  but  universally  used  in  pus 
cases,  either  alone  or  combined  with  rubber  or  glass 
drainage  tubes.  Morris^"  first  employed  an  iodoform 
wick,  and  later  a  special  device  consisting  of  a  slen- 
der piece  of  gauze  wrapped  about  with  perforated  rub- 
ber tissue.  As  regards  the  use  of  iodoform  gauze, 
opinions  of  experienced  men  vary  widely.  Morris,  for 
instance,  in  1897,  published  a  tirade  against  the  use 
of  gauze,  iodoform  and  plain,  while  Murphy,  in  the 
same  year,  returns  to  the  use  of  iodoform  gauze  after 
having  completely  discarded  it  for  a  time. 

Very  recently  a  tendency  to  close  immediately  the 


29 


abdominal  wall  for  primary  union  in  some  cases  of 
appendicitis  with  pus  is  becoming  manifest.  Schuel- 
ler,"'  in  1S89,  was  the  first,  I  believe,  successfully  to 
close  the  abdomen  at  once  and  entirely  after  an  appen- 
dicectomy  at  which  he  found  turbid  serum  in  tl">e  peri- 
toneal cavity.  Clark,'"  in  1897,  alludes  to  instances 
of  similar  practice,  and  Boldt  informs  me  that  he  has 
several  times  operated  successfully  in  the  same  man- 
ner in  cases  in  which  a  small  amount  of  pus  was 
present. 

A  curious  accident,  tearing  off  of  the  distal  end  of 
the  appendix  during  enucleation  of  the  latter,  and  fail- 
ure to  find  again  the  distal  end,  is  recorded  by  Hunt- 
ington.'" The  writer  has  had  a  similar  experience; 
both  cases  ended  in  recovery,  without  drainage. 
Hutchinson'"'"  reports  an  operative  case  in  which  he 
found  the  appendix  at  some  distance  from  the  caecum, 
from  which  it  had  entirely  separated  by  sloughing. 

Statistical. — i^utopsy  statistics  of  appendicitis, 
large  "and  important  for  the  time  at  which  they  were 
presented,  have  been  given  by  Leudet,""^  Finnell,^'^ 
Toft,'''  Fitz,"''  Einhorn,'^'  Wallis,^^'  Ribbert,-^''  and 
Robinson.-"^  Kleinwaechter'"  and  With''"  have  fur- 
nished statistics  regarding  the  duration  of  appendicitis 
under  medical  treatment,  while  Sands'"^  and  Fitz'^^ 
investigated  the  mortality  under  medical  and  under 
surgical  treatment.  McBurnev"'"'  presents  personal 
statistics  of  operations  for  appendicitis  in  the  pres- 
ence of  diffuse  septic  peritonitis.  Von  Mayer^^*  gives 
us  a  very  unique,  practical,  and  interesting  study  of 
seventy-five  operative  cases  of  chronic  appendicitis. 
Of  these,  thirty-three  presented  clinical  symptoms 
corresponding  to  the  lesions  found,  thirty-two  pre- 
s-^nted  no  clinical  symptoms,  and  ten  had  severe  symp- 
toms with  no  lesions.  Statistics  of  operative  cases, 
with  mortality,  have  been  published  by  Clay,^"  Bull," 
MacDonald,-'^  Murphy,''"''  Johnson,'"''  Kuemmeii,'®' 
Sonnenburg,""  Deaver,""  Halliday,'^*  and  very  numer- 
ous others. 


30 

Illustrations. — Appendicitis  has  furnished  a  favor- 
ite subject  for  the  artist's  pencil  and  brush,  and  it  is 
not  too  much  to  say  that  perhaps  upon  no  other  sub- 
ject in  the  entire  range  of  pathology  has  such  wide- 
spread, profuse,  elaborate,  and  beautiful  illustration 
been  lavished.  I  call  attention  in  the  following  to 
those  illustrations  which  have  struck  me  as  particu- 
larly noteworthy;  they  constitute,  however,  only  a 
modicum  of  the  whole. 

The  anatomy  of  the  appendix  and  its  vicinity  has 
been  thoroughly  illustrated  by  Little,'"*  Schueller,^'^ 
Lockwood  and  Rolleston,'"^  Levings,"""  Kelynack,^'^ 
and  Jonnesco,'^**  The  general  pathology  has  been 
well  pictured  by  Fenger,''^  Fowler,'-^  Jessop,'"  Plum- 
mer,'"'"  Lannelongue,''^  Smith, ^■'^  and  Sonnenburg^'^ 
among  others,  while  the  histo-pathology  has  been  espe- 
cially well  delineated  by  Letulle  and  Weinberg.'"" 
Chronic  appendicitis  has  received  the  artistic  atten- 
tions of  Foges"" ;  interval  appendicitis  those  of  Abbe' ; 
appendicitis  obliterans  those  of  Senn^'^  and  Zucker- 
kandl"*"';  and  the  location  of  abscesses  those  of  Har- 
ris.^^^  Intestinal  strangulation  following  appendicitis 
has  been  pictured  by  most  of  those  already  enumerated 
as  having  described  cases,  while  some  of  the  operative 
sequelae  have  been  delineated  by  Peck.""*  Cysts  and 
cystic  degeneration  of  the  appendix  have  been  well 
pictured  by  Gruber,'''  Gouillioud,"'  Shoemaker,'"' 
Sonnenburg,^"  and  Coats."' 

Among  illustrations  of  other  pathological  conditions 
affecting  the  appendix  the  following  may  be  men- 
tioned :  Invagination  of  the  appendix,  by  McKidd  '"^ ; 
prolapse  of  mucous  membrane  of  the  appendix,  by 
Rolleston'"";  thrombosis  of  appendicular  vessels,  by 
Dieulafoy";  tuberculosis  of  the  appendix,  by  Apert '"; 
and  primary  cancer  of  the  appendix,  by  Mosse  and 
Daunic.'*^  The  technics  of  the  operation  for  appen- 
dicitis have  been  abundantly  illustrated  by  many 
writers,  among  others  by  Ruth,'"^  Deaver,''  Fowler, 


124 


31 


and  Morris.-"  The  article  of  Ruth  contains  beautiful 
illustrations  detailing  the  technics  of  the  stump. 
Deaver's  admirable  plates  are  the  only  ones  I  have 
found  illustrating  the  rectus  incision.  Five  cuts  de- 
tailing post-operative  sequelae  in  a  very  interesting 
case  are  given  by  Peck,"" 

Literature. — ^The  entire  literature  of  appendicitis, 
complete  to  the  beginning  of  the  year  1899,  and  in- 
cluding, in  addition,  about  fifty  numbers  appearing 
during  the  present  year,  has  been  consulted  in  the 
preparation  of  this  article.  This  vast  literature  em- 
braces, as  already  stated,  more  than  twenty-five  hun- 
dred journal  articles,  dissertations,  and  books,  A 
complete  bibliography,  prepared  by  the  author,  may 
be  found  in  the  library  of  the  New  York  Academy  of 
Medicine,  where  it  is  at  the  disposal  of  any  one  who 
may  wish  to  consult  it. 

The  appended  bibliography  of  three  hundred  and 
seventy-six  references  is  believed  to  include  nearly  all 
of  real  value  that  has  been  published  upon  the  sub- 
ject of  appendicitis.  It  includes  papers  and  books  » 
important  and  valuable  for  the  time  at  which  they 
were  published,  together  with  a  number  of  articles  to 
which  reference  became  necessary  in  the  preparation 
of  this  historical  review. 

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